What medications are used to treat insomnia?

Medications for Sleep (Insomnia)

First-Line Treatment: Non-Pharmacological Approach

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be initiated before any medication, as it demonstrates superior long-term efficacy compared to pharmacological options with minimal adverse effects. 1, 2

• CBT-I includes stimulus control therapy, sleep restriction, relaxation techniques, and cognitive restructuring 3
• Sleep hygiene education alone is insufficient but should include: maintaining consistent bed/wake times, avoiding caffeine and alcohol near bedtime, keeping the sleep environment dark and quiet, and avoiding heavy meals before bed 1, 3
• CBT-I can be delivered through individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books—all formats show effectiveness 2, 3

Pharmacological Treatment: When CBT-I is Insufficient

First-Line Medications

When pharmacotherapy is necessary, short-intermediate acting benzodiazepine receptor agonists (BzRAs) or ramelteon should be used at the lowest effective dose for the shortest duration (4-5 weeks maximum). 1, 2, 3

For Sleep Onset Insomnia:

• Zolpidem 10 mg (5 mg in elderly) at bedtime 1, 3, 4
• Zaleplon 10 mg at bedtime 1, 3
• Triazolam 0.25 mg at bedtime (though associated with rebound anxiety) 1, 3, 5
• Ramelteon 8 mg at bedtime (melatonin receptor agonist with lower abuse potential) 1, 3

For Sleep Maintenance Insomnia:

• Eszopiclone 2-3 mg at bedtime 1, 3
• Zolpidem 10 mg (5 mg in elderly) at bedtime 1, 3
• Temazepam 15 mg at bedtime 1, 3
• Suvorexant 10-20 mg (orexin receptor antagonist) at bedtime 1, 2, 3
• Low-dose doxepin 3-6 mg at bedtime 1, 3

Second-Line Medications (When First-Line Fails)

If initial BzRAs or ramelteon are unsuccessful, consider alternative agents in the same class first, then sedating antidepressants particularly when comorbid depression/anxiety exists. 1, 3

• Trazodone 25-100 mg at bedtime (though AASM suggests NOT using it based on limited evidence) 1
• Mirtazapine 7.5-30 mg at bedtime 1
• Olanzapine 2.5-5 mg at bedtime (only for patients with comorbid conditions benefiting from antipsychotic effects) 1
• Quetiapine 2.5-5 mg at bedtime (only for patients with comorbid conditions) 1

Medications NOT Recommended

The following agents should NOT be used for insomnia due to lack of efficacy data, safety concerns, or problematic side effects: 1, 3

• Over-the-counter antihistamines (diphenhydramine 50 mg) - risk of daytime sedation, delirium, especially in elderly 1, 3
• Melatonin 2 mg supplements 1, 3
• Valerian and other herbal supplements 1, 3
• L-tryptophan 250 mg 1
• Tiagabine 4 mg (anticonvulsant) 1, 3
• Barbiturates and chloral hydrate 1, 3

Critical Safety Considerations and Monitoring

All hypnotic medications carry significant risks including daytime impairment, complex sleep behaviors (sleep-driving, sleep-walking), falls, fractures, cognitive impairment, and potential for dependence. 1, 2, 4

• FDA labels warn of driving impairment the morning after use, behavioral abnormalities, worsening depression, and anterograde amnesia 1, 4
• Elderly patients require lower doses (e.g., zolpidem 5 mg maximum) due to increased sensitivity and fall risk 3, 4
• Patients should be followed every few weeks initially to assess effectiveness, side effects, and need for ongoing medication 1, 3
• Prescriptions should be written for short-term use (7-10 days for triazolam, up to 35 days for zolpidem) and not exceed a 1-month supply 4, 5

Treatment Algorithm

Step 1: Initiate CBT-I with sleep hygiene education for all patients 1, 2, 3

Step 2: If CBT-I insufficient after 4-6 weeks, add (not replace) pharmacotherapy based on symptom pattern:

• Sleep onset difficulty → zolpidem, zaleplon, ramelteon, or triazolam 1, 3
• Sleep maintenance difficulty → eszopiclone, zolpidem, temazepam, doxepin, or suvorexant 1, 3

Step 3: If first-line medication unsuccessful, try alternative BzRA or ramelteon 1, 3

Step 4: If still unsuccessful and comorbid depression/anxiety present, consider sedating antidepressants (mirtazapine, low-dose doxepin) 1, 3

Step 5: For refractory cases with comorbid conditions, consider atypical antipsychotics (olanzapine, quetiapine) only when primary action of drug provides additional benefit 1

Common Pitfalls to Avoid

• Never use medications as monotherapy without implementing CBT-I techniques 1, 2, 3
• Never prescribe long-term without periodic reassessment (every few weeks initially, then regularly) 1, 3
• Never combine multiple sedative medications due to exponentially increased risks of cognitive impairment, falls, and complex sleep behaviors 3
• Never ignore underlying sleep disorders - if insomnia persists beyond 7-10 days of treatment, evaluate for sleep apnea, restless legs syndrome, or circadian rhythm disorders 1, 3
• Never use long-acting benzodiazepines (e.g., flurazepam) due to increased risks without clear benefit 3
• Never prescribe higher doses than recommended - use lowest effective dose for shortest duration 1, 2, 3

Special Populations

Palliative Care Patients (Life Expectancy Weeks to Days):

• Chlorpromazine 25-100 mg PO/PR at bedtime may be considered when patient desires treatment 1
• Adjust approach based on patient's goals of care and desire for symptom management 1

Patients with Substance Use History:

• Avoid benzodiazepines; prefer ramelteon or suvorexant due to lower abuse potential 3

Elderly Patients:

• Use half the standard adult dose (e.g., zolpidem 5 mg instead of 10 mg) 3, 4
• Avoid antihistamines completely due to high risk of delirium and falls 3